Age as a prognostic factor for head and neck squamous cell carcinoma: should older patients be treated differently?

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Age as a prognostic factor for head and neck
squamous cell carcinoma should older patients
be treated differently?

• Udi Cinamon 1, Michael P. Hier 2, Martin J. Black
  2
• 1 - Department of Otolaryngology, Head Neck
  Surgery,
• Wolfson Medical Center, Holon, Israel
• 2 - Department of Otolaryngology, Head Neck
  Surgery,
• Jewish General Hospital, McGill University,
  Montreal
• Special thanks to CISEPO
• (Canada International Scientific Exchange Program)

2
Old age Jim Barry
3
Children should not be treated as small adults
!!! Should elderly patients be treated
differently?
4

• Introduction
• Improved medical care
• New surgical techniques, i.e., reconstructive
• surgery
• Progress in the field of anesthesia
• Enable a more aggressive treatment to patients
• with HNSCC.
• HOWEVER
• Feasibility appropriateness?

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Epidemiology
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2.7
7
2.7
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Incidence
Age
Mortality
Age
75
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In Israel / Canada the average age 75-? / 82-?

• Living in an aging society
• We may expect to treat more seniors with HNSCC

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• Objective
• To explore the issue of proper treatment
• in an aging society.
• To address the question
• feasibility appropriateness?

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Methods

• A retrospective study of the treatment outcome
• for patients that were primarily treated on
  our
• service 1990-1999.
• Patients 75 years with HNSCC
• of the oral cavity, pharynx and larynx.

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Results

• 40 Pts
• 75-99 years (average, 82.2)
• 26? and 14?

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Distribution of patients according to stage and
primary site of tumor.
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Co-morbidityPre treatment medical evaluation
according to the ASA Classification of Physical
Status system.
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Treatment modalities and staging.
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Major complications for 36 Pts treated for cure

• Post operative mortality - 2
• Cessation of radiotherapy - 1
• Free flap complication - 1
• Hospital stay gt 6 weeks - 3

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Treatment outcome and survival data

• 4 Pts - Stage IV received palliative
  radiotherapy.
• Dead of disease after 4 months (2-6
  mon.).
• 2 Pts that were treated with a curative
  intention
• Postoperative mortality
• 34 Pts that were treated with a curative
  intention
• 11 - Recurrence
• 2 - Metastasis
• Survival of the 34 Pts. was 4.7 years (3
  mon.11y) .

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Treatment outcome and survival data

• Stage I 15 Pts Average follow up - 6 years.
• 3 Pts had a recurrence and treated. None died
  from cancer related causes.
• Stage II 3 Pts one died after 2 years with no
  evidence of disease.
• Second patient recurred after one year,
  treated, and is alive 4 years after with NED. The
  third recurred locally after 9 months, for which
  he was treated surgically. He had a fatal
  myocardial infarction a week after his operation.
  
• Stage III 5 Pts One had a jejunum free flap and
  died of post-operative complications.
• Two are alive with NED after 6 years, another
  died after 4 years with NED, the fourth had a
  recurrence after 5 years and died soon after from
  an un-related cause.
• Stage IV 13 Pts five were dead of disease
  within 3-15 months, two with distant metastasis.
  One patient recurred had a fatal MI a week after
  been treated surgically.
• One died 9 months after treatment having an
  acute MI. Two died with NED after 4 and 6 years.
  One patient was free of disease for 10 years and
  died from lung cancer. Three patients are living
  with NED after 5, 6, and 7 years, the latter had
  a recurrence after one year that was treated
  surgically.

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Discussion

• An intention to cure HNSCC necessitates a
  vigorous treatment which by itself may jeopardize
  the patient.
• Investigation of the association between age and
  treatment-outcome reveals conflicting opinions.

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Main outcome of studies

• Koch et al.(1995), McGuirt Davis (1995)
• Older Pts have more complications.
• Clayman et al. (1998)
• same complication rate and
• almost the same recurrence mets rate.

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Main outcome of studies

• Shaari et al. (1998,1999), Blackwell et
  al.(2002), studies of surgicalfree flap outcome
• Seniors have more medical complications and
  almost the same flap/surgical complication rate.
•  
• Sarini et al. (2001) 273 Pts75y.
• Decision making according to age
• older?less aggressive treat more XRT/ less
  surgery
• Almost the same results as younger Pts.

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Main outcome of studies Hirano Mori
(1998) The treatment outcome of 37 patients
that were eligible for curative treatment but
preferred palliative treatment was significantly
worse compared to those treated for cure.
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• Summary
• Decision making
• Age was not an exclusion factor from receiving
  curative treatment.
• Pts. medically eligible ? for curative
  treatment.
• The survival of Pts. treated for cure was 4.7
  years, while the life
• expectancy of the general population (of 82 y
  old) is about the
• same (6.3 y).
• Conclusion
• Seniors having HNSCC do benefit from curative
  treatment.
• Therefore, exclusion from receiving such
  treatment should be
• based, as for younger subjects, on a careful
  individual basis.

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Thank You